Acute Pelvic Inflammatory Disease Case File

Acute Pelvic Inflammatory Disease Case File

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 24

An 18-year-old adolescent woman presents to the emergency department (ED) complaining of a 1-week history of abdominal pain. She tells you that she and her friends recently returned from spring break vacation in Mexico, and she has noticed a constant ache that is worse on her right side. The patient’s mother is worried because her daughter has been unable to eat or drink anything for 2 days and thinks she may have become sick from drinking the water while on vacation. After asking the mother to step out of the room while you examine the patient, she tells you that she has had five sexual partners, occasionally uses condom for birth control, and has never been pregnant. Her last menstrual period was 2 weeks ago and was heavier than normal. On physical examination, her blood pressure was 100/70, pulse 110 beats per minute, respirations 22 breaths per minute, and temperature 38.9°C (102.1°F). Her heart has a regular rate and rhythm without murmurs. Lungs are clear to auscultation bilaterally. The abdominal examination reveals a diffusely tender lower abdomen, greater on the right than left and the patient exhibits voluntary guarding. Examination of the pelvis reveals a greenish, foul-smelling discharge with a red, friable-appearing cervix. Bimanual examination reveals an exquisitely tender cervix with fullness and pain in the right adnexal area. DNA assays for gonorrhea and Chlamydia are collected. The wet prep of the discharge shows many white blood cells (WBCs), no clue cells, no trichomonas, and no Candida. A urine pregnancy test is negative.

⯈ What is the most likely diagnosis?

⯈ What is the next diagnostic step?

⯈ What is the next step in your treatment?

ANSWER TO CASE 24:

Acute Pelvic Inflammatory Disease

Summary: An 18-year-old nulliparous adolescent woman complains of severe abdominal pain, vaginal discharge, fever, nausea, and vomiting. She displays cervical motion tenderness and her right adnexa appear to have some fullness and tenderness on examination.

• Most likely diagnosis: Pelvic inflammatory disease.
• Next step: Transvaginal ultrasound to rule out tubo-ovarian abscess, complete blood count (CBC), and screen for sexually transmitted infections (STIs).
• Next treatment step: Admit the patient and start IV antibiotic therapy.

ANALYSIS

Objectives

1. Understand the diagnosis and workup of pelvic inflammatory disease.
2. Describe the lack of clinical signs of tubo-ovarian abscess.
3. Know the criteria and treatments for both outpatient and inpatient pelvic inflammatory disease.
4. Know the common differential diagnoses for lower abdominal pain and be able to consult the appropriate specialties based on the physical examination and laboratory studies.

Considerations

This nulliparous adolescent woman has lower abdominal pain, fever, abnormal vaginal discharge, adnexal tenderness/fullness, and cervical motion tenderness. Although these symptoms may occur with other diagnoses such as appendicitis, ovarian torsion, ectopic pregnancy, or inflammatory bowel disease, the clinical symptoms are most consistent with pelvic inflammatory disease (PID). PID is defined as an ascending infection from the vagina or cervix to the upper genital tract, such as the endometrium, fallopian tubes, or ovaries. Although the etiology may be polymicrobial, sexually transmitted organisms such as Neisseria gonorrhoeae or Chlamydia trachomatis are implicated in many cases. Because the disease may mimic other common conditions, meticulous physical examination, clinical examination, and use of transvaginal ultrasound must be performed in conjunction to correctly diagnose a gynecologic disease from that of a general surgery process. This patient is admitted to the hospital due to inability to tolerate oral medication (nausea and vomiting) and also height of the temperature (37.8°C [102°F]).

Approach To:

Pelvic Inflammatory Disease

DEFINITIONS

CERVICAL MOTION TENDERNESS: Also referred to as a “chandelier sign.” Motion of the cervix during bimanual examination elicits extreme tenderness, so as to cause the patient to jump off the bed and hit the chandelier.

PELVIC INFLAMMATORY DISEASE (PID): An ascending infection of microorganisms from the lower genital tract to the upper genital tract that is polymicrobial, but is commonly caused by N gonorrhoeae or C trachomatis. PID may also be termed salpingitis.

TUBO-OVARIAN ABSCESS (TOA): A collection of purulent material encompassing the fallopian tube and ovary comprised of predominantly anaerobic organisms. TOAs are an important complication of pelvic inflammatory disease.

CLINICAL APPROACH

Pelvic inflammatory disease is an ascending infection from the lower genital tract to the upper genital tract that may be difficult to diagnose due to the variety and severity of presenting symptoms. Risk factors for the development of PID are young age, recent menstruation, multiple sexual partners, no use of barrier contraception, and lower socioeconomic status. The clinical diagnosis of PID is fairly accurate but a broad differential diagnosis should be kept in mind in the evaluation of abdominal pain in a woman. Criteria for diagnosis include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness. The presence of purulent vaginal discharge, fever more than 101°F, elevated serum leukocyte count, and presence of gonorrhea or Chlamydia in the endocervix are supportive findings. Thus, all women who are suspected of having PID should have testing for N gonorrhoeae and C trachomatis as well as HIV.

The clinical presentation of tubo-ovarian abscess can be subtle. The majority of these patients have little or low-grade fever, slightly elevated white blood cell count, and may not have a palpable adnexal mass on pelvic examination. For this reason, those patients who are diagnosed with PID should have imaging of the pelvis to assess for TOA, since this diagnosis requires in-patient therapy.

Ultrasound imaging or computed tomography (CT) imaging of the abdomen and pelvis may be helpful to assess for other conditions. The differential diagnosis of acute PID includes appendicitis, ectopic pregnancy, endometriosis, ovarian torsion, hemorrhagic corpus luteum cyst, benign ovarian tumor, and inflammatory bowel disease. CT imaging is more helpful in assessing appendicitis. Finally, laparoscopy is considered the “gold standard” in establishing the diagnosis, by visualizing purulent discharge from the tube, and is generally considered when a patient has acute symptoms, sepsis, or is not improving on therapy.

The etiology of PID is polymicrobial as many different bacteria are harbored in the vagina. Most commonly, N gonorrhoeae and C trachomatis are isolated from a cervical culture, but other organisms, such as Bacteroides fragilis, Escherichia coli, Peptostreptococcisp, Haemophilus influenzae, and aerobic streptococci, have been isolated from acute cases of PID. Thus, organisms may be classified as either sexually transmitted organisms or endogenous.

The pathogenesis of PID may include many mechanisms. First, for ascension of infection to develop from the vagina, through the cervical canal, to the endometrium of the uterus, through the fallopian tubes and to the ovaries or peritoneum, there must be a breakdown of the natural host defense system. For instance, hormonal changes unique to a woman’s cycle may play a role in the ascending infection. During a normal menstrual cycle, the cervical mucus changes based on the predominate hormone, either estrogen or progesterone. At midcycle, when estrogen predominates and progesterone is low, cervical mucus is thin and may facilitate easy ascension of bacteria. Whereas after ovulation, when progesterone is low, the cervical mucous is thick and more difficult for bacteria to penetrate. For this reason, progestin-containing contraception via the oral contraceptive or depot medroxyprogesterone acetate (depo provera) decreases the incidence of PID. Menses is another time when woman are at greater risk for developing PID because the cervical mucous plug is lost due to outward menstrual flow and organisms may also ascend to the upper genital tract. Retrograde menstrual flow has also been attributed to the risk of bacteria ascending from the uterus into the fallopian tubes, ovaries, or peritoneal cavity.

Treatment of PID varies widely depending on the clinical presentation of the patient. Treatment should provide broad-spectrum coverage of the suspected pathogens, and should be initiated as soon as a presumptive diagnosis has been made in order to prevent long-term sequelae or complications from acute PID, such as tubal damage leading to infertility, chronic pain, or ectopic pregnancies. Of note, postinfectious tubal infertility is the second most common reason for female infertility in the United States.

Uncomplicated PID in a compliant patient may be treated as an outpatient. However, certain criteria for hospitalization exist for the management of complicated PID (Table 24–1). Although IV antibiotics are used to treat the symptoms of PID, laparoscopy is useful in cases with an uncertain diagnosis, suspicion of a ruptured TOA, or when a patient fails to respond to IV antibiotics. A ruptured TOA

Data from Centers for Disease Control and Prevention. 2010 Guidelines for treatment of sexually transmitted diseases.

MMWR. 2010;59(RR-12):1.

presents as shock, and is a surgical emergency. Thus, the patient who is brought into the emergency department with hypotension, significant abdominal pain, and a signs of infection should receive fluid resuscitation and arrangements for rapid surgical management.

Treatment options can be divided into oral treatment and parenteral treatment. Fluoroquinolone-resistant gonorrhea has rendered quinolone therapy as a secondary regimen. Outpatient management includes intramuscular ceftriaxone and oral doxycycline 100 mg twice daily for 14 days with or without metronidazole (Table 24–2). Patients should ideally be seen back in 48 hours to assess for improvement. A common inpatient management is intravenous cefotetan 2 g every 12 hours and oral or IV doxycycline 100 mg every 12 hours. Improvement should occur after 24 to 48 hours of therapy. When a tubo-ovarian abscess is suspected, clindamycin or metronidazole is used in the place of doxycycline since anaerobic bacteria are the main concern. TOAs are an exception to the rule that “abscesses require drainage”—the majority of TOAs can be treated with antibiotic therapy and followed with imaging for resolution. Approximately one-third of TOAs will need surgical therapy.

After clinical improvement on intravenous therapy, the patient is changed to oral antibiotic therapy for 10 days. If there is no improvement after 72 hours of therapy (decreased fever, improvement in abdominal pain, reduction in uterine/ adnexal tenderness), a more in-depth workup is needed. Follow-up and treatment of a known sexual partner is essential for decreasing the incidence of recurrence of PID. Known complications are infertility, pelvic adhesions leading to chronic pelvic pain, risk of ectopic surgery, Fitz-Hugh-Curtis syndrome, and chronic PID.

COMPREHENSION QUESTIONS

24.1 A 22-year-old woman is noted to have lower abdominal pain associated with some dysuria and abnormal menses. Her appetite has decreased recently. The pregnancy test is negative. Which of the following findings would most likely suggest pelvic inflammatory disease?

A. Endometrial biopsy showing atypical cells

B. Vaginal wet mount demonstrating clue cells

C. Cervical motion tenderness on physical examination

D. Pain on rectal examination

24.2 A 32-year-old woman is noted to have a 2-day history of low-grade fever and lower abdominal tenderness. The examination reveals cervical motion tenderness and adnexal tenderness. Which of the following is best in assessing for possible tubo-ovarian abscess?

A. Degree of temperature

B. Elevation of leukocyte count

C. Pelvic examination revealing adnexal mass

D. Ultrasound of the pelvis

E. Rebound tenderness of the abdominal examination

Match the following diseases (A to F) to the clinical situations in Questions 24.3 to 24.6:

A. Ectopic pregnancy

B. Appendicitis

C. Gastroesophageal reflux disease (GERD)

D. Crohn disease

E. Cholelithiasis

F. Pancreatitis

G. Ovarian torsion

24.3 A 21-year-old woman experiences crampy abdominal pain that begins near the umbilicus and moves to the lower right quadrant. The pain has progressed over days, and is intermittent and crampy. The patient is afebrile and complains of some nausea.

24.4 A 41-year-old woman complains of pain in the upper abdomen especially after eating. The pain seems to travel to her right shoulder. She has bloating at times.

24.5 A 35-year-old man complains of epigastric abdominal pain which seems to “bore straight to the back.” He has nausea and vomiting.

24.6 A 22-year-old woman complains of intermittent severe abdominal pain with diarrhea. She also has some joint pain.

ANSWERS

24.1 C. Although cervical motional tenderness is not specific for acute salpingitis, and can be seen with other acute inflammatory conditions of the lower abdomen such as diverticulitis and appendicitis, it is a classic finding of pelvic inflammatory disease.

24.2. D. Imaging is the best way to assess for TOA. Tubo-ovarian abscess is often subtle in its presentation and may not be associated with fever or elevated WBC. Most TOAs can be treated medically with antibiotics rather than requiring surgical therapy.

24.3 G. The intermittent crampy abdominal pain is classic for ovarian torsion. Although this patient’s pain moves from the umbilicus to the lower quadrant area, it has lasted longer than 24 hours, without fever.

24.4 E. The right upper quadrant abdominal pain following meals (especially fatty meals) is very typical of cholelithiasis. The pain often radiates to the right scapula. If she had fever, cholecystitis would be suspected.

24.5 F. Pancreatitis usually presents with midepigastric pain that penetrates straight to the back, is constant in nature, and is associated with nausea and vomiting. Common etiologies include alcohol abuse and gall stones.

24.6 D. Inflammatory bowel disease (Crohn disease or ulcerative colitis) often affects individuals in their teens or twenties, with abdominal pain, diarrhea (often bloody), and extraintestinal manifestations such as joint pain or eye findings.

CLINICAL PEARLS

⯈ The classic triad of symptoms for diagnosing PID include lower abdominal tenderness, adnexal tenderness, and cervical motion tenderness.

⯈ Laparoscopy remains the gold standard for diagnosing PID.

⯈ TOAs often present in a subtle or indolent fashion and require imaging for diagnois. TOAs require hospital antibiotic therapy and the majority can be treated medically.

⯈ Patients with a ruptured TOA present in shock. This is a surgical emergency.

⯈ Long-term sequelae of PID include infertility, pelvic adhesions, chronic pelvic pain, risk of ectopic pregnancy, and Fitz-Hugh-Curtis syndrome.

⯈ Disseminated gonococcal infection, although uncommon, is a serious complication of untreated gonorrhea, which is a very common infection.

⯈ Persons found to have a positive gonorrhea culture should also be treated for Chlamydia because concomitant infection is found in as many as 40% of patients. In any person presenting with asymmetric polyarthritis, tenosynovitis, and pustular skin lesions, disseminated gonococcal infection should be considered in the differential diagnosis.

References

Centers for Disease Control and Prevention. 2010 guidelines for treatment of sexually transmitted diseases. MMWR. 2010;59(RR-12):1. 

Cohen CR. Pelvic inflammatory disease. In: Klausner JD, Hook III EW, eds. Current Diagnosis & Treatment of Sexually Transmitted Diseases. New York, NY: McGraw-Hill; 2007. 

Hemsell DM. Gynecologic infection. In: Schorge J, Schaffer J, Halvorson L, Hoffman B, Bradshaw K, Cunningham F, eds. Williams Gynecology. New York, NY: McGraw-Hill; 2008: 73-76. 

Sweet RL, Gibbs RS. Infectious Diseases of the Female Genital Tract. 5th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2009.

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